Eczema – an incurable but fairly successfully manageable disease

Psoriasis – a chronic inflammatory skin disease caused by immune mechanisms that needs to be constantly and long-term treated. The characteristic rash of psoriasis consists of erythematous well-defined papules and plaques covered with large, wax-like scales, appearing in various parts of the body. It is a severe disease that worsens the quality of life for many patients. Since psoriasis is a visible aesthetic issue, constant rash and scaling affect dressing style, clothing color, lifestyle, work nature, sports, and hobbies. Patients with psoriasis are concerned not only about the disease itself but also about the negative attitude of others, as it is still believed that this disease is contagious. Therefore, we discuss the most relevant issues of psoriasis diagnosis, its management, and treatment possibilities with the dermatologist at the Clinic of Dermatology and Venereology of the Lithuanian University of Health Sciences, Dr. Vesta Kučinskiene.Psoriasis is a chronic systemic disease, often affecting the joints. Has the disease changed its face recently, and who are the most common age groups affected by it?

According to the latest research data, psoriasis is unevenly prevalent in various ethnic groups. It most commonly affects the population of Northern Europe, less frequently – Africa and Asia. Psoriasis symptoms usually appear in people aged 15-35, with about 75% of patients experiencing symptoms before the age of forty. However, psoriasis can affect people of any age. Approximately every tenth patient develops symptoms of psoriasis in childhood. The earlier the symptoms appear, the higher the likelihood of the disease spreading and recurring constantly.

The clinical features of psoriasis are very diverse and change little, dermatovenereologists easily recognize psoriasis rashes – reddish, well-defined scaly plaques. However, as correctly noted, attention is increasingly drawn to the fact that it is not only a skin and joint disease but a systemic disease causing inflammation of internal organs and significantly worsening the patient's quality of life over time.

What advice would you give to patients trying to "live with" this disease, how to avoid disease exacerbations, and live a normal life?

Although the disease is chronic, it can now be managed quite successfully. I would advise patients not to give up, communicate more with family members, with other psoriasis patients, not to hide, actively participate in various activities, seek advice from a dermatologist not only about medications but also about healthy living, nutrition. If necessary, find time for consultations with other specialists, such as a rheumatologist, psychologist, etc.

How can psoriasis and its exacerbations be controlled today? Perhaps there are radical treatment methods already? What are the main principles of psoriasis treatment? Is most attention really paid to topical medications? Why?

Currently, patients with moderate to severe psoriasis can be treated with biological drugs. There are more opportunities to individually select treatment and control psoriasis exacerbations for a longer period. The doctor prescribes psoriasis treatment based on its severity and spread index. It is believed that the patient could calculate it himself. Based on its size, it is possible to better understand whether the disease is under control or whether it is necessary to consult a doctor and change medications. Psoriasis affects 75-85% of patients on a small area of the skin, the rashes are not widespread, so most patients only need topical medications. They are needed for many patients being treated with ultraviolet rays or systemic medications, including biological ones.

What problems would you identify with the use of local impact medications: perhaps they are influenced by the patient's inappropriate attitude towards the disease, violations of the treatment regimen (dislike of using ointments, time-consuming application, drug intolerance due to unpleasant smell, greasiness, inconvenient use, etc.)?

Since the disease is chronic, applying skin ointments takes a long time. Many people get tired, or simply do not have the time or opportunity to apply the medication two or even several times a day because they work or study. And if the doctor prescribes several local impact medications, it is more likely that the patient will not adhere to the prescribed treatment regimen, especially if it is not precisely explained how to use the medications. A review of the use of local impact medications revealed that 44% of patients are dissatisfied with the slow absorption of the drug into the skin, 41% of patients are bothered by the need to apply the medication more than once, 34% indicated that the greasy cream often stains clothes and bedding, 20% of patients simply lack knowledge about the disease and its treatment, and only 5% of patients do not take medication due to a lack of funds.

 

One of the first-line local impact measures is a combination product of calcipotriol and betamethasone. In what cases is treatment with this ointment recommended, and what are its usage peculiarities?

The combination ointment of calcipotriol and betamethasone dipropionate is much more effective than its individual components because it has a stronger anti-inflammatory and antiproliferative effect. By suppressing inflammation, the glucocorticoid reduces the irritation caused by calcipotriol, while calcipotriol reduces the side effects of the glucocorticoid. Therefore, this combination drug can be used for a longer period than a single local glucocorticoid. Recently, in Lithuania, a gel form of the combination of calcipotriol and betamethasone dipropionate was registered. The gel form of the drug is less greasy, does not stick to clothes, spreads more quickly on the body surface, and is therefore more convenient and willingly used by patients, especially since the medication only needs to be applied once a day. This form of medication is suitable for treating both scalp psoriasis and skin rashes on the body.

 

Many patients and doctors have been afraid of hormone preparations due to the skin atrophy they cause when used for a long time. The latest publication in 2014 provides data that calcipotriol reduces the likelihood of skin atrophy caused by betamethasone - this should be good news for both doctors and patients.

Local glucocorticoids, by reducing fibroblast proliferation, intercellular filler protein production, and affecting skin cells differently, promote skin atrophy. Calcipotriol, by activating vitamin D receptors, acts in the opposite way on cellular and molecular mechanisms, thus protecting against skin atrophy. Clinical studies have shown that the combined betamethasone and calcipotriol drug can be effectively and safely used for up to a year without causing skin atrophy. This confirms that the combination of calcipotriol and betamethasone preparation is safer and more effective than pure hormonal local impact medications.

 

The usual daily care of a patient with eczema is left to the family doctor. However, in which cases should a patient be referred for a dermatologist consultation?

I think if the patient wants a more detailed consultation, the family doctor should not object to it. The patient should be referred to a dermatologist in cases where the rashes are very widespread or, if the rashes, although small, but treated with the same medication for a long time, remain red, flaky, and unchanged.